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Headache evaluation.

  1. 1. Evaluation of headache Dr. Ravi Shankar Sharma A.I.I.M.S,Jodhpur
  2. 2. Steps of evaluation • Causes and red flags • ICHD-3 classification • History • Examination • Investigations
  3. 3. Pain generators Extracranial structures • Scalp • Muscles • Cervical • TMJ joint • Paranasal sinuses • Teeth Intracranial structures • Blood vessels • Meninges • cranial nerves
  4. 4. Harrison’s neurology in clinical medicine-4th edition
  5. 5. Red flags
  6. 6. Classification (ICHD-3) • The Primary Headaches 1. Migraine ( ± Aura) 2. Tension-type headache (Infrequent, Frequent,Chronic) 3. Trigeminal autonomic cephalalgias. 4. Other primary headache disorders
  7. 7. The Secondary Headaches 5. Headache attributed to trauma or injury to the head and/or neck 6. Headache attributed to cranial and/or cervical vascular disorder 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection 10. Headache attributed to disorder of homoeostasis 11. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure 12. Headache attributed to psychiatric disorder
  8. 8. Painful Cranial Neuropathies, Other Facial Pain and Other Headaches 13. Painful lesions of the cranial nerves and other facial pain 14. Other headache disorders
  9. 9. Detailed classification ICHD-3 http://www.ihs-headache.org/ichd- guidelines
  10. 10. History 1. Age of onset:  Migraine , TTH, Cluster headache-early (20-30yr.)  Secondary headache- late onset
  11. 11. Location
  12. 12. Intensity • Migraine – moderate /severe • TTH- Mild to mod. • Cluster – very severe • Sudden & severe- SAH
  13. 13. Character of headache
  14. 14. Duration • Migraine – 4 to 72hr. • TTH- up to 7 days • Cluster & other TACs- sec. to min.
  15. 15. • Cluster -1 to 8/day at a particular time • • Migraine- 1-4attacks/month • TTH- <1 day/month to >15 days/month
  16. 16. Aggravating/relieving factor • Migraine – ↑menses, stress , empty stomach etc. ↓ sitting in dark room • Cluster headache- ↑ Alcohol, vasodilators (NTG) • TTH- ↓ Rest & meditation • ↑ICT/Arnold chiari malformation- ↑ valsalva
  17. 17. Triggers Visual stimuli Flashing Lights Anxiety, Stress and Physical exertion Lack of Sleep Hormonal ChangesHeadache Foods Tyramine Caffeine: 18 Drugs Weather changes Psychological factors Disturbed sleep pattern Auditory stimuli Olfactory stimuli Hunger
  18. 18. Associated feature • Nausea & vomiting- migraine, ↑ ICT, Infections • Autonomic symptoms- cluster headache • ↑ ICT, pituitary tumours - visual field defects • Aura symptoms & premonitory symptoms- Migraine
  19. 19. Prodromal symptoms include Lethargy Craving for food Distaste for foods
  20. 20. Visual Auras
  21. 21. Impact on the daily activity Migraine disability assessment(questionnaire) Some doctors like to estimate how much migraines disrupt normal activities before treatment begins. A questionnaire is given to the patient to estimate how often they miss various functions (school, work, family activities) because of migraines. 22
  22. 22. Family history • Familial hemiplegic migraine – genetic influence • Sec. headaches like cerebral aneurysm, brain tumours.
  23. 23. Past history • Change in character, pattern & severity of new headache ( ? d/t sec. headache) • Episodic to chronic type
  24. 24. Medicinal history • OCP’s • HRT • Antihistaminics • Nitrates  Medication overuse headache(Rebound headache)
  25. 25. Co morbidities • Dental , nose, sinus or ear abnormalities Infection • H/O head trauma • Asthmatics – avoid Beta- blockers • Depression & insomnia- Amitriptyline
  26. 26. • Physical examination- If any abnormalities– Investigations & imaging • General examinations- Body habitus- Fever Blood pressure Skin changes
  27. 27. Systemic examination Central nervous system: 1. Higher functions- a) Memory b) Concentration c) Speech d) Orientation Higher function can be assessed by Mini Mental scale
  28. 28. a) Neck – Local inflammation, R.O.M, Nucheal rigidity(Meningitis, SAH,postr. Fossa tumr. b) Face – symmetry, ear, nose, eyes & teeth. c) Scalp- swelling & redness
  29. 29. Palpation
  30. 30. • Percussion :- Tinel’s sign • Auscultation :-Bruits over carotid/vertebral arteries, orbits
  31. 31. Cranial nerve examination
  32. 32. 1. Plain X-ray skull and cervical spine ( #/trauma) 2. CT scan-#,PNS collection, I.C. lesion 3. MRI- Infarcts , Hemorrhage 1. MR angiography/venography
  33. 33. Diagnostic blocks
  34. 34. Migraine without aura/common migraine A. At least five attacks fulfilling criteria B–D B. Headache attacks lasting 4–72 hours (when untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis.
  35. 35. Migraine with aura/classic migraine A. At least two attacks fulfilling criteria B and C B. One or more of the following fully reversible aura symptoms: 1. visual 2. sensory 3. speech and/or language 4. motor 5. brainstem 6. retinal C. At least two of the following four characteristics: 1. at least one aura symptom spreads gradually over5 minutes, and/or two or more symptoms occur in succession 2. each individual aura symptom lasts 5-60 minutes 3. at least one aura symptom is unilateral 4. the aura is accompanied, or followed within 60minutes, by headache D. Not better accounted for by another ICHD-3 diagnosis, and transient ischaemic attack has been
  36. 36. Tension-type headache 2.1 Infrequent episodic tension-type headache • A. At least 10 episodes of headache occurring on<1day per month on average (<12 days per year) and fulfilling criteria B-D 2.2 Frequent episodic tension-type headache • A. At least 10 episodes of headache occurring on 1-14 days per month on average for >3 months(12 and<180 days per year) and fulfilling criteria B-D
  37. 37. C. At least two of the following four characteristics: 1. bilateral location 2. pressing or tightening (non-pulsating) quality 3. mild or moderate intensity 4. not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. no nausea or vomiting 2. no more than one of photophobia or phonophobia E. Not better accounted for by another ICHD-3 diagnosis.
  38. 38. Cluster Headache A. At least five attacks fulfilling criteria B–D B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated) C. Either or both of the following: 1. at least one of the following symptoms or signs,ipsilateral to the headache: a) conjunctival injection and/or lacrimation b) nasal congestion and/or rhinorrhoea c) eyelid oedema d) forehead and facial sweating e) forehead and facial flushing f) sensation of fullness in the ear g) miosis and/or ptosis 2. a sense of restlessness or agitation D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active E. Not better accounted for by another ICHD-3 diagnosis
  39. 39. Thank you
  40. 40. References : • Headache classification committee of the international headache society (IHS).The international classification of headache disorders,3rd edition (beta version). Cephalgia.2013, vol33(9) 629-808 • Headache classification committee of the international headache society (IHS).The international classification of headache disorders,3rd edition. Cephalgia.2018, vol38(1) 1-211 • Waldman. Atlas of common pain syndrome 2nd ed. • Waldman . Atlas of uncommon pain syndrome • Das. Clinical methods in pain medicine. 2nd ed. • www.ichd-3.org

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